CQC report explained · a residential care home
What the CQC found at Clapham Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement, with an Inadequate well-led rating and serious concerns about falls, staffing, medicines and management.
This was an unannounced focused inspection. Inspectors visited the home on 7 February 2023 and gathered further information until 28 February. They spoke with people, relatives, staff and visiting professionals, and reviewed care, medicines, staffing, accident and incident records, recruitment documents, audits and policies.
The home was not always safe. Falls were not recorded fully, and there was little evidence that lessons were learned or action was taken to prevent repeat falls. There were not always enough staff, care staff were also cooking, medicines were given with interruptions, and some infection control practices were not followed.
The home was rated Inadequate for being well-led. Records, complaints and significant events were not managed properly. Audits did not identify important problems, and there was not enough oversight of safety and quality. The overall rating changed from Good at the previous inspection to Requires Improvement.
The inspection only rated Safe and Well-led. The other key question ratings were carried forward from the previous inspection because they were not reviewed during this visit. The provider was asked to send an action plan, and CQC said it would monitor progress with the local authority.
Safe recruitment
Recruitment checks included references from previous employers and Disclosure and Barring Service checks.
“The provider followed safe recruitment practices which included requesting references from previous employers and checks with the Disclosure and Barring Service (DBS).” from the report
People felt safe
People and relatives said they felt safe living at the home. Staff understood how to raise safeguarding concerns.
“People and their relatives told us they felt safe living at Clapham Lodge Care Home.” from the report
Mental capacity practice
Inspectors found that the home was working within the principles of the Mental Capacity Act and that required legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Falls were not managed reliably
seriousFalls records were incomplete and did not show whether action had been taken to prevent repeat incidents. This created a risk of harm and was part of a breach.
“Systems were either not in place or robust enough to demonstrate safety was effectively managed. This placed people at risk of harm.” from the report
Not enough staff at some times
seriousPeople and staff reported pressure at certain times. Care staff also routinely carried out cooking because there was only one chef, and this was part of a breach.
“The provider had failed to ensure there were sufficient numbers of staff deployed. This placed people at risk of harm.” from the report
Medicine safety concerns
needs fixingSome liquid medicines did not have opening dates, and records did not show whether time-specific medicines were given at the correct time. Staff also reported being interrupted during medicine rounds.
“Staff expressed concern that the deployment of staff meant they were constantly interrupted whilst giving people their medicines.” from the report
Weak management and records
seriousAudits failed to identify important problems. Care and service records were incomplete or inconsistent, including differences in fluid records.
“The provider had not ensured that effective systems and processes were in place to assess, monitor and improve the quality and safety of the service.” from the report
Complaints were not recorded
needs fixingConcerns raised by staff and relatives were not documented, and there was no evidence that action had been taken. This was part of a breach of good governance.
“Concerns and complaints were not documented.” from the report
Significant events not reported
seriousThe provider did not notify CQC of all significant events. This was a breach of the registration regulations.
“The providers failure to notify the Care Quality Commission of significant events was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.” from the report
- 01What has changed to make sure every fall is recorded, investigated and followed by action to prevent it happening again?
- 02How many care staff are on duty at busy times, and are they still expected to carry out cooking or other extra tasks?
- 03How are medicine rounds protected from interruptions, and how do you check that time-specific medicines are given at the right time?
- 04How are complaints, safeguarding concerns and significant events now recorded and reported to CQC?
- 05What evidence can you show that audits now identify and fix problems with care records, staffing and safety?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 22 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2018
Rated Good; inspectors found safe, kind and personalised care, with clear improvements since the previous inspection.
Inspectors visited on 29 October and 1 November 2018. The first day was unannounced and the second was announced. They spoke with people living in the home, relatives, staff and healthcare professionals, observed care, and checked care, medicines, staffing and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were treated with kindness, dignity and respect. Inspectors found that staff supported people's health, food and drink needs, activities, independence and contact with the community.
The home had improved since its previous Requires improvement rating in 2017. Records were clearer, and new systems had been introduced for medicines, fire safety and call bells. A new extension had been built, but its rooms were not registered with the CQC at the time of this inspection.
Kind and respectful care
People and relatives described staff as kind, patient and respectful. Inspectors found that people were involved in decisions about their care.
“People were supported and treated with dignity and respect; and actively involved in their care.” from the report
Safe medicines
Medicines systems and records were organised, and people received medicines when they should. The home also used technology to support time-sensitive Parkinson's medicines.
“Medicines systems and records were organised, and people received their medicines when they should.” from the report
Personalised support
Staff knew people's choices and communication needs. The home provided activities and adapted communication for people with hearing loss or after a stroke.
“People's personalised needs were consistently met through planning that involved them and by being listened to.” from the report
New rooms not yet registered
minorThe home had built an extension with new rooms, but these were not registered with the CQC when inspectors visited. The provider planned to register them.
“These were not registered with us at the time of the inspection but the provider planned to do this.” from the report
- 01Has the extension and its new rooms now been registered with the CQC?
- 02How are staffing levels checked at different times of day, and what do the call bell response records show?
- 03How would you support my relative if they needed time-sensitive Parkinson's medicines or other medicines at particular times?
- 04How would you adapt communication if my relative had hearing loss, dementia or difficulty communicating?
- 05How are families involved in advanced care planning and decisions about end of life care?
This was a scheduled, planned comprehensive inspection after the previous Requires improvement rating, and it assessed all five key questions as well as the premises and care provided. This explanation was written from the published report of 7 December 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Clapham Lodge Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 15 December 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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28 live-in carers within about an hour of West Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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